This project will analyze the evolution of federal government policy toward endstage renal disease from the early 1960s through 1972. Through several discrete time periods, policy development has included provision of treatment for veterans, biomedical research, organizational feasibility of delivering care, development of treatment capacity, and enactment of patient-care financing as near-universal entitlement. Critical factors affecting policy development include the clinical status of hemodialysis and transplantation (emergence of therapies, status as experimental v. therapeutic, emergence of different modalities within each therapy), the medical-scientific community (changes in distribution of power among medical specialists, institutional ambivalence and innovation in delivery of services); interaction of medical community with policy system (exercise of power over government programs, derivation of power from programs); role of political actors (constraint and encouragement of policy development); role of federal bureaucracy (importance of Veterans Administration in policy development, Public Health Service, policies and programs); and effect of state government programs on federal policy. A "tipping" process is postulated as the mechanism of action leading to 1972 legislation, i.e., Medical coverage for end-stage renal disease; the cumulative effect of a number of incremental changes in medicine and policy throughout the 1960s and early 1970s lead to the threshold-crossing policy of the 1972 legislation. Research methods will involve interviews of key policy actors and analysis of documents pertaining to major episodes and events. Strong interaction (briefings, interviews, correspondence, informal review of draft report) with the medical-scientific community is proposed. The product of the project will be a Rand report suitable for publiation by the National Center for Health Services Research. Significance of this research lies in analysis of (1) emergence, validation, and diffusion of major clinical innovation, especially medical technology, (2) dynamics of policy formulation in a system of uncoordinated interdependence, and (3) decision making regarding the allocation of scarce medical resources.